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i4OT <br />SAN JOAQUIN COUNTY <br />t.kENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />Depth of Well Seal Waiver <br />Well Permit Number: %rjLk) 77 <br />This application is made for a waiver of the minimum annular space Well Seal Depth required <br />by San Joaquin County Well Standards at the following location: <br />Site Address: ,x&52 L/�/Y//nom /1l% APN: <br />City: t ,—&,- ' &nr7 4-120 <br />This Waiver is requested due to the following circumstances: <br />This Waiver i approved baked on the following: <br />/. )X�� �a .r 1 -,-A , r i <br />c <br />Approved by: Date: l <br />egistered Environmental Health Specialist <br />The following conditions are placed on the well construction permit and may not be modified: <br />1. The property owner shall sign this application and acknowledge that the well <br />construction deviates from minimum depth of well seal standards. <br />2. The annular seal shall terminate in an impervious layer. <br />3. To verify the water quality from the well, yvater sam I s shall be aI for the <br />following chemicals of concern: <br />I, the undersigned owner of the property identified above, hereby request a Waiver from <br />the minimum well seal depth standards of San Joaquin County based on the information <br />noted above. I acknowledge that this Waiver information should be disclosed to <br />subsequent property owners. f <br />Signature oil Property Owner: <br />: Date: <br />Print Name: Y <br />Mailing Address: 5-;z Ag�Y5:&StreeAddress City Zip Code <br />EHD 43-05 DEPTH OF WELL SEAL WAIVER <br />4/30/12 <br />